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HEAD INJURY

ByDr. Keiza .N.

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DEFINITION

Trauma to the head.

Neurological disruption.

Variable presentation.

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INCIDENCE

In the USA, 500,000 new cases

10% die before hospital.

10% are severe. 10% are moderate.

80% are mild.

Many deaths and comorbidities can bereduced through prompt referral .

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ANATOMY

Scalp- five layers: skin, connective tissue,aponeurosis ,loose areolar tissue andpericranium

skull: cranial vault- smooth, some areas thin.pterioncranial base is irregular- anterio and middle

cranial fossa

Meninges: three layers. Dura mater,arachnoidand pia.

Brain specific functions

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ANATOMY(cont)

Cerebrospinal fluid-30ml per hour, from

choroid plexus

Tentorium- supra and infratentorial

compartments .Tentorial incisura edge

closely related to third cranial nerve and

uncus

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PHYSIOLOGY

Intracranial pressure normal 10mmHg or 136mm water.

Above 20mmhg is abnormal

Monroe Kellie doctrine -brain+blood +csf is aconstant. Initial compensation, eventuallyexponential rise.

Cerebral perfusion CPP=MAP-ICP. Perfusion

pressure of

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CLASSIFICATION

Mechanism of injury- blunt or penetrating

Severity of injury-GCS

Morphology of injury- skull orintraparenchymal

Primary or secondary

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SKULL FRACTURE

Linear

Depressed

These could be open or closed

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PATHOLOGY

Primary brain injury- at impact

Secondary-complications-:

-haematoma

-brain swelling

-hypoxia

-infection

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INTRACRANIAL BLEED

Epidural

Subdural

Subarachnoid intracerebral

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MANAGEMENT

History

Physical examination

Radiological investigationsskull radiograph,

cat scan,

MRI

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PRIMARY SURVEY

A.-ABCDE

B-Immobilize and stabilize the cervical

spine

C-Perform a brief neurological exam

1.pupillary response.

2.GCScore determination.

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SECONDARY SURVEY

A-.Inspect the entire head. Remove dressings ,look forlacerations or csf

B-Palpate for fractures including the wounds

C-Inspect all scalp lacerations-look out for

brain,depressed fractures,debris or csf D-Minineurological examination--GCS -BEST

- -Eye

-Motor- - Verbal

Pupillary responseE-Examine cervical spine

F-Determine the extend of the injury

G-Regular reassessment

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INVESTIGATIONS

A-Radiographs

B-CT SCAN

-scalp

-bone-subdural/epidural space

-surface sulci

-brain parenchyma

-ventricles-midline structures and basal cisterns

-posterior fossa

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SPECIFIC MANAGEMENT

MILD HEAD INJURY-GCS 14 or 15

-Approx 80% of pts in A &E have mild HI-majority recover fully

-3% deteriorate suddenly-ideally, all with long period of loc shouldhave a CT scan-ideally admit for observation for 24 hours-advise to come back in case of anywarning signs

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MODERATE HEAD INJURY

GCS 9-13

Approx 10 % of patients in A&E departm

May have focal signs. 10-20% may deteriorate

Up to 40% have abnormal scans

Admit even if CTscan is normal

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SEVERE HEAD INJURY

GCS 3-8

Cannot follow commands

Up to 30% are hypoxaemic-

13% hypotensive

12% anaemic

Combination of hypoxia and hypotensionleads up to 75% mortality.

Admit all and protect airway from early

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HAEMATOMA-SUBDURAL

CTscan confirmation

Indications for surgery:

-focal neurological signs

-altered loc

-features of raised ICP

Burr holes or craniotomy

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EPIDURAL HAEMATOMA

CT confirmation

Usually ruptured middle meningeal artery

occasionally dural venous sinus rupture

Indication for surgery focal signs or

raised ICP

craniotomy

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INTRACEREBRAL HAEMATOMA

Indication for surgery -raised ICP

Safe access of the haematoma is very

important

Craniotomy

Deficits may persist

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LINEAR FRACTURE

Simple -no indication for surgery

Compound- theatre for surgical

debridement and stitching

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DEPRESSED SKULL FRACTURE

Closed elevation in case it is significant

Compond- Theatre for surgical

debridement and elevetion

Antibiotic cover

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RAISED ICP

Ventillatory support

Mannitol

lasix

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Extradural haematoma

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Subdural haematoma

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Bilateral subdural haematoma

acute on chronic

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Bilateral subdural haematoma MRI

findings

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Brain oedema

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Post-craniotomy extradural

haematoma

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Post-craniotomy extradural

haematoma

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Intracerebral haematoma with

marked brain swelling

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Intracerebral haematoma